Postoperative Adhesion Formation After Peritoneoscopy with Liver Biopsy in a Survival Porcine Model: Laparotomic vs Laparoscopic vs NOTES® Transgastric Approach

Abstracts

S1391 Hopkins CCK-Stimulated TcHIDA Scintigraphy with Calculation of SOD Score Should Be the First Step in the Evaluation of PostCholecystectomy Patients with Suspected Biliary Type III Sphincter of Oddi Dysfunction David B. Liang, Sumit Kapoor, Devi Mukkai Krishnamurty, Patrick Okolo, Marcia I. Canto, Anthony N. Kalloo, Sanjay B. Jagannath, Samuel A. Giday

S1393 Postoperative Adhesion Formation After Peritoneoscopy with Liver Biopsy in a Survival Porcine Model: Laparotomic vs Laparoscopic vs NOTESÒ Transgastric Approach Elena Dubcenco, Lia R. Assumpcao, Kathleen Gabrielson, Xavier Dray, Dawn Ruben, Laurie J. Pipitone, Gianfranco Donatelli, Devi Mukkai Krishnamurty, Jeffrey P. Baker, Michael R. Marohn, Anthony N. Kalloo

A non-invasive diagnostic test to accurately identify patients with Type III sphincter of Oddi dysfunction (SOD) would be ideal. One such test is the use of dynamic hepatobiliary scintigraphy after stimulation with cholecystokinin, and with calculation of a SOD score based upon hepatic to duodenal transit time. The use of this diagnostic test has been controversial. Our center has the largest volume and experience with this test. Aim: To assess the utility of CCK-stimulated TcHIDA scan with calculation of SOD score (CCK HIDA) in predicting the clinical response in patients with suspected Type III SOD who were treated with endoscopic biliary sphincterotomy. Methods: Retrospective review of patients who underwent CCK HIDA followed by ERCP from 2001 to 2008 at Johns Hopkins Hospital. A CCK HIDA score O5 was positive for the non-invasive diagnosis of biliary SOD. Inclusion criteria included: age O18, Post-cholecystectomy status, biliary colic with suspected Type III SOD who underwent CCK HIDA followed by ERCP with biliary sphincterotomy. Patient demographics, clinical history, laboratory parameters and symptomatic response after biliary sphincterotomy were recorded. Bivariate and multivariate logistic regression analysis was performed. Variables for the final logistic regression model were selected by using stepwise procedures, and the most parsimonious predictive model was chosen. Results: 5500 patients underwent TcHIDA scan at Johns Hopkins Hospital from 2001 to 2008. Eighty nine patients fulfilled the criteria for study. Majority of the patients were female (90%) and Caucasians (87%). The mean age of the patient population was 48 years. Positive CCK HIDA scores were found in 68 (76.4%) patients of which 49 (72%) had a clinical response to sphincterotomy. Of those patients with a negative CCK HIDA (21), over half (57.6%) had no response following sphincterotomy. Using response to treatment as gold standard, CCK HIDA was found to have a sensitivity of 81.6% and a positive predictive value of 72%. Bivariate regression analysis showed that response to sphincterotomy in those patients with a positive CCK HIDA was 2.34 times more likely than patients with a negative result. In addition, ageO50 years and female gender were more likely to have an abnormal CCK HIDA scan (Odds Ration of 4 and 1.7 respectively). No single laboratory parameter was able to predict response to treatment in our population. Conclusion: Given the morbidities of ERCP in patients with SOD, CCK HIDA appears to be a useful screening test for the non-invasive diagnosis of Type III SOD, and should be part of the algorithm in evaluating Type III SOD patients.

Background: Adhesions are an almost inevitable consequence of laparotomy and laparoscopy, although laparoscopic surgery produces fewer adhesions than laparotomy. It is suggested that minimizing the invasiveness of the operative technique by using NOTESÔ may reduce adhesion formation. Objective: The aim of the study was to compare the rate of the adhesion formation after peritoneoscopy with liver biopsy by laparotomy, laparoscopy and transgastric NOTESÔ. DESIGN: Experimental comparative survival study. Setting: Research facility of the Johns Hopkins University School of Medicine. Patients: 18 female pigs that weighed 35-40 kg were used. Interventions and Methods: Peritoneoscopy with liver biopsy was randomized to 1 of 3 groups: control, laparotomy (nZ6); laparoscopy (nZ6), NOTESÔ transgastric (nZ6). Pre-operative, operative, and post-operative care was standardized. The Hopkins Adhesion Formation score method was used to assess adhesion formation. The following parameters were evaluated 1) extent - (the abdomen was divided into 4 quadrants - left upper quadrant, right upper quadrant, left lower quadrant and right lower quadrant; number of involved abdominal quadrants was documented); 2) frequency (number of bands); 3) size/width (total size/width of all adhesions was measured and summed total for every animal); 4) organ involvement (number of organs involved); 5) density of the adhesions; 6) dissectibility of the adhesions; and 7) vascularization. MAIN OUTCOME MEASUREMENTS: (1) Survival and complication rates (2) Necropsy (Day 14) (3) Assessment of adhesion formation rate using the Hopkins Adhesion Formation Score; (4) Differences between the groups by oneway analysis of variance (ANOVA) followed by a Tukey post-test analysis (5) Pearson product moment correlation coefficient (r-value) between the adhesion scores of two investigators. Results: There was no mortality in any study group. 100% of pigs in laparotomy group, 33.3% in laparoscopy group had adhesions compare to 16.7% in transgasric NOTESÔ group. One adhesion band was documented in Group III (transgastric NOTESÔ), 4 adhesion bands in Group II (laparoscopy) and 17 in Group I (laparotomy). The mean adhesion formation scores of laparotomy and laparoscopy were 2.4 and 0.8 compared with 0.17 in the transgastric NOTESÔ (P! 0.001). The Correlation coefficient between the adhesion scores of two investigators was r Z 0.99 (p ! 0.001, 95% CI). Limitations: Low number of study animals. Conclusions: Rate and severity of adhesion formation was lower in the transgastric NOTESÔ group compared to laparoscopy and laparotomy, when peritoneoscopy with liver biopsy was performed.

S1392 Transvaginal NOTESÒ Cholecystectomy: Postoperative Gynecological Evaluation Oscar M. Laudanno, Santiago Horgan, Julieta Paleari, Anibal Rondan, Alberto R. Ferreres Background: The development of NOTES procedures raise issues regarding new ways of access to the abdominal cavity. The transvaginal access through posterior colpotomy has been widely used by gynecologists for the treatment of several conditions and has many advantages over other access (transgastric, transrectal and trans-vesical). Objective: Assessment of the postoperative gynecological impact, both anatomical and functional, after transvaginal NOTES cholecystectomy. Patients and Method: 22 female patients were operated between August 2007 and September 2008. All patients fulfilled the following requirements: a)symptomatic gallbladder stones, b) previous pregnancy, c) abscense of common bile duct obstruction d) negative pregnancy tests, e) normal mini- mental test . The gynecologic screening evaluation included: interrogation, examination including colposcopy and pelvic-transvaginal ultrasound. A transvaginal NOTES cholecystectomy was attempted in the 22 patients with a hybrid technique: with laparoscopic control via a 5 mm umbilical trocar, a 2 way trocar was inserted trough the right posterior vaginal cul de sac which allowed the insertion of a videogastroscope, forceps and diverse instruments. Once cholecystectomy was performed it was removed through the vagina and closure was attained with a running suture of absorbable vycril 2/0. The postoperative follow up included gynecologic assessment at postoperative days 7, 30 and 60 and included guided questionnaire (patients satisfaction with the procedure, restart of sexual activity, spontaneous pain, dyspareunia), physical examination and colposcopy to assess healing, presence of anatomical injuries, vaginal secretion and other alterations. Results: the operation with the NOTES hybrid technique could be completed in 21 of the 22 patients (95%). In the remaining case the operation had to be performed laparoscopically due to pelvic adhesions (5 previous cesarean sections). One case required a minilaparotomy through a previous Pfannestiel incision for checking hemostasis of the vaginal cul de sac. The systematic assessment prove adequate healing of the vaginal access with no local complications. Two patients restarted sexual relations before the 30 days prescribed, and the rest followed compliance with the indications. None of the patients refer dyspareunia. Two patients got pregnant after the procedure and one underwent a normal birth delivery without complications. Conclusions: the transvaginal NOTES access proves to be safe, with excellent outcomes, no complications and void of negative impact in the gynecologic and sexual aspects.

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S1394 Comparison of Pain and Postoperative Stress in Dogs Undergoing Natural Orifice Translumenal Endoscopic Surgery (NOTES)Ò, Laparoscopic, or Open Bilateral Oophorectomy Lynetta Freeman, Emad Y. Rahmani, Mohammad A. Al-Haddad, Stuart Sherman, Michael V. Chiorean, Don J. Selzer, Peter D. Constable, Paul W. Snyder Background: Few studies are available to compare the potential benefits of NOTES to traditional surgery. Objective: Compare intra-operative complications, markers of surgical stress, and post-operative pain and recovery with NOTES versus laparoscopic and open abdominal oophorectomy. Design: Prospective study; Setting: Academic center; Subjects: 30 healthy female dogs underwent bilateral oophorectomy procedures performed via NOTES (nZ10), laparoscopic (nZ10) and traditional open (nZ10) approaches. Main outcome measurements: Operative time; surgical and postoperative complications; postoperative pain scores and nociceptive threshold; surgical stress markers (IL-6, C-reactive protein); systemic stress parameters (cortisol, glucose); 3 day clinical observation. Results: Mean operative times were 80 (STD 30), 44 (STD 9), and 37 (STD 12) minutes for the NOTES, laparoscopic and open procedures, respectively. All of the ovaries were completely excised and all dogs survived. One of the dogs in the NOTES group was excluded from postoperative monitoring due to temperament. Except for postoperative hypothermia, all physiologic parameters remained within expected limits in all animals. Serum glucose concentrations increased (P!0.05) after surgery and remained elevated for at least 36 hours with no differences between groups. Serum cortisol concentrations increased (P!0.05) from baseline at 2 hours after surgery in the laparoscopic group and at 2 and 4 hours after surgery in the open and NOTES groups. Serum IL-6 concentration was increased at 2, 6, and 12 hours compared to baseline in the NOTES group, but not in the open or laparoscopic groups, with no statistically significant differences between groups. Serum C-reactive protein concentration was significantly elevated in the NOTES animals from 6 to 72 hours compared to baseline and in the laparoscopic group at 12 hours. The mean pain score and the nociceptive threshold measurements revealed that the NOTES group demonstrated less evidence of pain than either the laparoscopic or open groups. Conclusions: NOTES oophorectomy in dogs appears to be as safe but presents a steep learning curve, requiring more time to perform

Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB161